Inspection Report
Re-Inspection
Census: 52
Capacity: 70
Deficiencies: 0
Apr 10, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 03/06/2025.
Findings
At this PSR, Wellbrooke of South Bend was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 70
Census: 52
Inspection Report
Complaint Investigation
Census: 44
Capacity: 77
Deficiencies: 0
Mar 20, 2025
Visit Reason
This visit was for the investigation of Complaint IN00454443.
Findings
No deficiencies related to the allegations of Complaint IN00454443 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00454443 - No deficiencies related to the allegations are cited.
Report Facts
Census: 44
Total Capacity: 77
Medicare Census: 26
Medicaid Census: 12
Other Payor Census: 6
Inspection Report
Annual Inspection
Census: 50
Capacity: 70
Deficiencies: 5
Mar 6, 2025
Visit Reason
An Emergency Preparedness Survey, Life Safety Code Recertification, and State Licensure Survey were conducted to assess compliance with Medicare and Medicaid participation requirements, emergency preparedness, and fire safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness requirements due to failure to conduct required emergency exercises. Life Safety Code deficiencies included improper exit signage, lack of approved method for returning cooking appliances to their designed location, failure to maintain fire alarm system inspections semi-annually, and improper storage and marking of oxygen cylinders.
Severity Breakdown
SS=F: 3
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures. | SS=F |
| Failed to ensure one of two doors to the outside was not mistaken as an exit; missing 'NO EXIT' signage. | SS=E |
| Failed to provide an approved method for returning cooking appliances to their designed location under the kitchen hood extinguishing system. | SS=E |
| Failed to maintain fire alarm system in accordance with NFPA 72; no documentation of semi-annual visual inspections. | SS=F |
| Failed to ensure oxygen cylinders were properly stored and segregated; empty cylinders not marked to avoid confusion and delay. | SS=F |
Report Facts
Certified beds: 70
Census: 50
Deficiencies cited: 5
Inspection Report
Recertification
Census: 54
Capacity: 88
Deficiencies: 5
Feb 6, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey and the Investigation of Complaints IN00448825 and IN00450672. The visit included a State Residential Licensure Survey.
Findings
The facility was found to have deficiencies related to resident grievance process anonymity, activities of daily living care for a dependent resident, food sanitation practices, hospice documentation, and infection control during blood glucose testing and insulin administration. No deficiencies were cited related to the complaints investigated.
Complaint Details
Complaint IN00448825 and Complaint IN00450672 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=E: 2
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to have a process for residents to file a grievance anonymously, as the electronic grievance app required staff assistance, potentially removing anonymity. | SS=E |
| Facility failed to provide activities of daily living (shaving) for a dependent resident (Resident 4). | SS=D |
| Facility failed to serve food in a sanitary manner by serving a plate with a thumb touching the top of the plate. | SS=E |
| Facility failed to ensure coordination of Hospice care and maintain up-to-date hospice documentation for Resident 21. | SS=D |
| Facility failed to follow standard precautions during blood glucose testing and insulin administration for Resident 21, including inadequate hand hygiene. | SS=D |
Report Facts
Residents affected by grievance deficiency: 54
Residents affected by ADL deficiency: 1
Residents affected by food sanitation deficiency: 9
Residents reviewed for hospice care: 1
Residents reviewed for infection control: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Named in infection control deficiency for improper hand hygiene during blood glucose testing and insulin administration. | |
| Executive Director | ED | Provided policy and information related to grievance process and food service. |
| Life Enrichment Director | LED | Helped residents file grievances and acknowledged anonymity issues. |
| Social Services Director | SSD | Helped residents file grievances and acknowledged anonymity issues. |
| CNA 8 | Provided information on shaving practices. | |
| CNA 9 | Provided information on shower and shaving schedules. | |
| LPN 10 | Indicated Resident 4 should have been shaved. | |
| Director of Food Service | Provided information on proper food handling. | |
| Director of Nursing | DON | Indicated hospice binder deficiencies and policy absence. |
| Clinical Support Nurse | Indicated lack of hospice book policy. |
Inspection Report
Renewal
Deficiencies: 0
Feb 6, 2025
Visit Reason
The inspection was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey.
Findings
Wellbrooke of South Bend was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 49
Capacity: 88
Deficiencies: 0
Oct 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435562.
Findings
No deficiencies related to the allegations in Complaint IN00435562 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00435562 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 88
Census Payor Type Total: 49
Census SNF/NF: 14
Census SNF: 35
Census Residential: 39
Census Medicare: 19
Census Medicaid: 14
Census Other: 16
Inspection Report
Life Safety
Census: 47
Capacity: 70
Deficiencies: 0
Jun 7, 2024
Visit Reason
A 2nd Post Survey Revisit (PSR) to the 1st PSR for the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with Life Safety Code requirements.
Findings
At this Life Safety Code PSR, Wellbrooke of South Bend was found in compliance with Medicare/Medicaid participation requirements, Life Safety From Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies.
Report Facts
Facility capacity: 70
Census: 47
Generator power: 300
Inspection Report
Follow-Up
Census: 41
Capacity: 70
Deficiencies: 3
Apr 29, 2024
Visit Reason
This was a Post Survey Revisit (PSR) conducted to follow up on previous Emergency Preparedness and Life Safety Code deficiencies cited on 03/18/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies were noted related to incomplete annual inspection and testing of fire door assemblies and generator maintenance and testing. The facility failed to implement systemic plans of correction to prevent reoccurrences of these deficiencies.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure annual inspection and testing of 7 of 12 fire door assemblies in accordance with NFPA 80 requirements. | SS=F |
| Failed to ensure an annual fuel quality test was performed for the facility's diesel powered generator as required by NFPA 110. | SS=F |
| Failed to exercise the diesel generator monthly and perform required load bank testing to meet NFPA 110 standards. | SS=F |
Report Facts
Certified beds: 70
Census: 41
Fire door assemblies inspected: 5
Fire door assemblies total: 12
Load bank test date: Jan 5, 2021
Generator exercise frequency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karl Steinhaus | Executive Director | Named in relation to findings and plan of correction discussions. |
| Director of Plant Operations | Involved in fire door inspection and generator maintenance findings and corrective actions. |
Inspection Report
Life Safety
Census: 38
Capacity: 70
Deficiencies: 9
Mar 18, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards including deficiencies in emergency preparedness policies, staff training, building construction maintenance, fire alarm system testing, sprinkler system maintenance, fire drills, fire door inspections, generator maintenance, and improper use of power strips.
Severity Breakdown
Level F: 5
Level E: 3
Level C: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure emergency preparedness policies and procedures include provision of subsistence needs for staff and residents and proper staff knowledge of the Emergency Preparedness Plan. | Level F |
| Failed to conduct annual training for the Emergency Preparedness Program and demonstrate staff knowledge of emergency procedures. | Level F |
| Failed to maintain building construction type due to a 1/4 inch penetration in ceiling fire barrier not properly sealed. | Level E |
| Failed to maintain fire alarm system with required semi-annual visual inspections and smoke detector sensitivity testing every two years. | Level F |
| Failed to maintain sprinkler system; several sprinkler heads were corroded, loaded with dust and foreign material. | Level E |
| Failed to conduct quarterly fire drills at unexpected times on all shifts for all quarters. | Level C |
| Failed to ensure annual inspection and testing of 27 fire door assemblies and 1 rolling fire door assembly. | Level F |
| Failed to document transfer time to alternate power source on monthly generator load tests and failed to perform annual fuel quality test and annual generator exercise per NFPA standards. | Level F |
| Used a power strip as a substitute for fixed wiring to power high current draw equipment in a patient care vicinity. | Level E |
Report Facts
Certified beds: 70
Census: 38
Fire door assemblies inspected: 27
Sprinkler heads loaded or corroded: 13
Fire drills: 4
Generator load tests: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karl Steinhaus | Executive Director | Signed report and involved in education and corrective actions |
| Director of Plant Operations | Interviewed and involved in findings related to emergency preparedness, fire safety, and maintenance |
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 6
Feb 20, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted over multiple days in February 2024.
Findings
The facility was found deficient in multiple areas including medication storage and labeling, food storage and sanitation, infection prevention and control practices, semi-annual resident evaluations, assisted living kitchen cleanliness, and securing medications for residents self-administering drugs. Corrective actions and staff education plans were outlined for each deficiency.
Severity Breakdown
SS=E: 1
SS=F: 1
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure medications were kept in a locked cart when unattended, medication carts were clean, medications were dated when opened, and over-the-counter medications had resident identifiers. | SS=E |
| Failed to store food under sanitary conditions including foods not tightly sealed, outdated foods, and dirty kitchen equipment. | SS=F |
| Failed to ensure proper infection control practices related to hand hygiene during peri-care and sanitary blood glucose testing. | SS=D |
| Failed to complete semi-annual evaluations for 2 of 7 residents reviewed. | — |
| Failed to ensure appliances were free from food debris, dishes were dry before storing, and dishwasher was at appropriate temperature in assisted living kitchenette. | — |
| Failed to secure medications in a resident apartment for a resident self-administering medications. | — |
Report Facts
Survey dates: 6
Census Bed Type - SNF/NF: 14
Census Bed Type - SNF: 33
Census Bed Type - Residential: 37
Total Census: 84
Census Payor Type - Medicare: 19
Census Payor Type - Medicaid: 14
Census Payor Type - Other: 14
Number of residents affected by infection control deficiency: 2
Number of residents affected by evaluation deficiency: 2
Number of residents affected by medication security deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karl Steinhaus | ED HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 3 | Interviewed regarding medication cart locking, medication storage, and blood glucose testing | |
| LPN 2 | Interviewed regarding medication storage on 100-hall medication cart | |
| CNA 4 | Observed and interviewed regarding peri-care hand hygiene | |
| CNA 6 | Observed during peri-care with CNA 4 | |
| Director of Nursing | DON | Provided policies and interviews regarding infection control and evaluations |
| Corporate Nurse | Provided policies and interviews regarding medication storage and infection control | |
| Dietary Manager | DM | Interviewed and observed during kitchen inspection |
| Director of Assisted Living | Interviewed regarding evaluations and medication security | |
| Director of Food Services | DFS | Responsible for auditing food service compliance |
Inspection Report
Renewal
Deficiencies: 0
Feb 20, 2024
Visit Reason
Paper Compliance Review to the Recertification and State Licensure Survey completed on February 20, 2024.
Findings
Wellbrooke of South Bend was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Nov 20, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00418996.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00418996 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 12
Census Bed Type: 11
Census Bed Type: 61
Census Total: 84
Census Payor Type: 12
Census Payor Type: 11
Census Payor Type Total: 23
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Jun 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406581.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00406581 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 12
Census Bed Type - SNF: 33
Census Bed Type - Residential: 40
Census Bed Type - Total: 85
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 12
Census Payor Type - Other: 19
Census Payor Type - Total: 45
Inspection Report
Annual Inspection
Census: 49
Capacity: 70
Deficiencies: 6
Jan 25, 2023
Visit Reason
The inspection was conducted as an Annual Life Safety Code Recertification and State Licensure Survey, including an Emergency Preparedness Survey, to assess compliance with Medicare and Medicaid participation requirements and life safety codes.
Findings
The facility was found not in compliance with several Life Safety Code requirements including hazardous area enclosure, cooking facilities protection, sprinkler system maintenance, emergency generator maintenance, and electrical equipment safety. Corrective actions were planned or completed for each deficiency.
Severity Breakdown
SS=E: 4
SS=F: 1
SS=B: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 storage rooms in the private dining area with large combustible storage and greater than 50 square feet was protected as a hazardous area; corridor door was not self-closing or automatic closing. | SS=E |
| Failed to maintain 1 of 1 kitchens in accordance with NFPA 96; deep-fat fryer located 6 inches from gas burners without protective shield/baffle plate. | SS=E |
| Failed to ensure 4 of 12 sprinkler heads in the kitchen were not loaded or covered with foreign material, violating NFPA 25 standards. | SS=E |
| Failed to maintain ceiling construction of 1 of 1 private dining area; missing ceiling tiles could delay sprinkler activation. | SS=E |
| Failed to ensure continuing reliability and integrity of 1 of 1 emergency generators; battery recommended for replacement but not yet replaced. | SS=F |
| Failed to ensure 1 of 1 flexible cords were installed properly and used safely; power strip was dangling and unsecured near water station. | SS=B |
Report Facts
Facility capacity: 70
Census: 49
Sprinkler heads deficient: 4
Sprinkler heads total: 12
Generator battery age: 4
Generator exercise frequency: 12
Generator full exercise interval: 36
Power strip audit duration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cassie Dunlap | Area Executive Director | Signed the report |
| Maintenance Director | Interviewed and involved in observations related to deficiencies | |
| Administrator | Participated in exit conference discussing findings | |
| Director of Plant Operations | Educated on deficiencies and responsible for corrective actions | |
| Executive Director | Educated staff and responsible for audits and corrective actions |
Inspection Report
Life Safety
Deficiencies: 0
Jan 25, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 01/25/23.
Findings
Wellbrooke of South Bend was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Recertification
Census: 37
Capacity: 81
Deficiencies: 10
Dec 15, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the investigation of Complaint IN00393796 which was unsubstantiated due to lack of evidence.
Findings
The facility was found to have multiple deficiencies including failure to maintain a safe, clean, comfortable environment, failure to provide adequate ADL care for dependent residents, failure to implement pressure ulcer prevention interventions, food safety violations, infection control issues, incomplete service plan documentation, and medication administration errors.
Complaint Details
Complaint IN00393796 was investigated and found to be unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Resident rooms and 1 kitchenette were not maintained in a clean safe environment with exposed plaster and loose baseboards. | SS=D |
| Failed to provide assistance for removal of facial hair for 1 of 4 residents reviewed for ADL care. | SS=D |
| Failed to implement interventions to prevent pressure ulcers for 1 of 3 residents reviewed. | SS=D |
| Failed to ensure kitchen utensils, pots, colanders and dishes were covered and inverted, extra powder thickener was not poured back into its original container, and clean thermometers were not stored in a sanitary manner. | SS=F |
| Failed to ensure a glucometer was disinfected thoroughly by nursing staff. | SS=D |
| Failed to ensure service plans were signed and dated by the resident for 3 of 7 clinical records reviewed. | — |
| Failed to ensure authorizations for PRN medications administered by a qualified medication aide were documented in the medical record. | — |
| Failed to ensure all food preparation and serving areas were maintained in accordance with state and local sanitation and safe food handling standards. | — |
| Failed to ensure nursing staff administering insulin via pen followed facility policy and manufacturer's instructions regarding insulin priming. | — |
| Failed to ensure emergency information files contained all required information including hospital preference for 3 of 7 records reviewed. | — |
Report Facts
Survey dates: 7
Census: 37
Total capacity: 81
Residents affected: 1
Residents affected: 1
Residents affected: 44
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 37
Residents affected: 1
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 10 | Licensed Practical Nurse | Observed failing to disinfect glucometer properly |
| QMA 11 | Qualified Medication Aide | Observed failing to prime insulin pen prior to administration and improper PRN medication documentation |
| Director of Nursing | Provided policy information and interviews regarding deficiencies | |
| Administrator | Provided policy information and interviews | |
| Cook 4 | Observed pouring thickener back into container | |
| Cook 5 | Observed improper thermometer placement and uncovered dishes | |
| Dietary Manager | Interviewed regarding food safety deficiencies | |
| Housekeeping Supervisor | Interviewed regarding maintenance issues | |
| Maintenance Director | Interviewed regarding maintenance issues |
Inspection Report
Renewal
Deficiencies: 0
Dec 15, 2022
Visit Reason
Paper Compliance to the Recertification and State Licensure Survey completed on December 15, 2022.
Findings
Wellbrooke of South Bend was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the Paper Compliance Review to the Recertification and State Licensure Survey.
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